Download OB NEST - Mayo Clinic

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The following pages detail the learnings and
insights from each of the experiments done as
part of the OB Nest project. Each experiment
seeks to uncover feasibility and potential within
the OB division as well as the overall impact
SIGNAL
on mom’s pregnancy experience.
NOR
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shift in
HOW DO WE CREATE A CLINICAL
PROCESS THAT LEVERAGES THE
99% OF PRENATAL NEEDS THAT
ARE MET OUTSIDE OF THE CLINIC?
Y
AUTONOMY
Joy
Wellness
Normalcy
Celebration
ALC
CONFIDENCE
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Confidence
Autonomy
Self-Awareness
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SELF AWARENESS
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STRENGTHEN
14 EXPERIMENTS | 120 PATIENTS
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EXPERIMENT REPORT
CONTEXT
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OB NEST
CONTEXT
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STRENGTHEN
SSA
Creating healthy outcomes
for MOMS & BABIES
W
A CONTINUOUS & C
DING TIONSHIP WITH ONNEC
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I
OB
TED
BU
RELA
Creating healthy outcomes
for MOMS & BABIES
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A CONTINUOUS & C
DING TIONSHIP WITH ONNEC
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OB
TED
BU
RELA
SIGNAL
SIGNAL
ACTIVATE
Partner
Family
Relatives & Friends
Communities
OB NEST TEAM
SIGNAL
DIVISION OF OBSTETRICS
Roger Harms, M.D. – Physician Lead
Amy Jasik
Kate Nesbitt
Increased CONNECTION to OB
Redefined CONTINUITY of Care
CENTER FOR INNOVATION
Marnie Meylor – Design Research
Dan O’Neil – Project Management
Andrea Brown
Matthew Gardner
Rachael Hamilton
Mekayla Beaver
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Creating healthy outcomes
for MOMS & BABIES
STATS
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Creating healthy outcomes
for MOMS & BABIES
SELF AWARENESS
CONFIDENCE
AUTONOMY
STRENGTHEN
STRENGTHEN
in
shift
• Having a direct link to her care team, archived
conversations,
CONTEXT and continuity of support staff makes
GTHEN
STRENROLE
mom’s
relationship
to the clinic feel more personal.
RHYTHM
“Just knowing this was
there was a subconscious
comfort. Even though you
wouldn’t know because I
didn’t use it that much”
• The act of contributing or “pushing” communication makes
moms feel like OB wants to hear from them and shifts the tone
from transaction to conversation.
Pregnant mothers were given a mobile application that
allowed them to text questions or concerns directly to SELF AWARENESS
CONFIDENCE
AUTONOMY
their care team outside of their face-to-face appointments.
A nurse was the primary recipient of the messages and
would respond if it was within her scope of practice. If it
wasn’t, she assigned the task to a physician.
• Tool improves ease of access to OB by utilizing mom’s
go-to mode of communication (text /email).
in
shift
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CONTEXT
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• Mom feels comfortable and secure knowing there
is a primary responder to her questions, and that this
HEN
GTan
STRENis
person
invested team member.
STRENGTHEN
DESCRIPTION
INSIGHTS
YT
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ASYNCHRONOUS
COMMUNICATION
OB TEAM
14 PATIENT USERS
A CONTINUOUS & CON
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Chris Domask
WITH O
ILD LAT146
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TED
BU
B
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between
April
Dr. Long
and July, 2012
Dr. Lessard
A CONTINUOUS & CON
ING
Dr. TanouyeBUILD RELATIONSHIP WITH OB NECTED
HY
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Experiment
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“I like that I
can ask any
question
at any time”
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CONFIDENCE
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CONTEXT
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• Even when patients aren’t using the tool,
they know it’s there if they need it which
creates a sense of security.
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SIGNAL
• The ability to send a concern via text or
in written form is a more private or secure
way to get pregnancy advice.
LL
NE
SS
RIT
Reinforces that prenatal care is
happening all the time, not only within the time
and space of an appointment.
SIGNAL
W
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L
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NORMALCY
CONTEXT
ROLE
CONFIDENCE
THEN
RHYTHM
STRENG
• Having direct and unobstructed access to the OB
department with questions welcome at any time gives
moms confidence.
N
HE
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STREN
• Even though women do not expect an immediate
response, it is comforting to have a place to
document questions and concerns as they
arise (instead of waiting until the morning, or
next appointment, etc.)
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AUTONOMY
• “Schedule call” feature needs to be visible and intuitive (currently it is
confusing, and not very visible)
• Tool must retain the ability to have a primary recipient: moms need to feel
like their messages are going to a familiar person.
• Enable seamless integration with EMR
• Recommended Capability: There is a need for profiles or bios for the people
that respond to a patient’s question
• Patients appreciate the dual web/mobile capability the tool offers
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NEXT PHASE Opportunity to leverage the connection mom has made with the OB clinic to
proactively establish and seamlessly transition her and her family’s postpartum care.
2
SELF AWARENESS
CONFIDENCE
Creating healthy outcomes
for MOMS & BABIES
Creating healthy outcomes
for MOMS & BABIES
STRENGTHEN
• Usage is contingent on predictable and reliable response time
• Needs message feedback (i.e. sent/received confirmation)
• Needs transparency about who is receiving/responding to messages
• Appropriate staff should be available to answer all pregnancy and
postpartum questions
• Interaction must be as simple as texting or email
• Because responses to patients’ questions vary in length and depth,
in order for this tool to be efficient, providers must have the ability to
respond to a message in three ways: schedule a call, audio memo, or text
CONTINUOUS & CO
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STRENGTHEN
TECHNICAL RECOMMENDATIONS
CONTINUOUS & CO
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ILDI LATIONSHIP WITH O
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BU
B
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PATIENT-FACING APP
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• Mom has evidence that her communication
is being collected and captured which
gives her confidence that she is being
remembered in the system.
• Tool captures and archives the complete
conversation, which better enables one
staff member to address an entire concern
thereby strengthening continuity
of care and ease of navigation.
“It makes the
time between
appointments
more tolerable because
you can be in contact at any
time with your provider – it
makes it more personal.
I always felt a little
uncomfortable when I had
to call in and I’m telling a
receptionist about
private concerns”
“
As a mom you’re managing
everyone’s care – sometimes you call in
and get one person, then you call again
and get another person. Then you repeat
your situation again – it’s cumbersome.
It’s nice to get the same person.
Email is the same thing, you can see the
whole conversation, so you aren’t
having to repeat yourself”
Experiment
ASYNCHRONOUS
COMMUNICATION
4-5 weeks until next appointment...
figure out
on my own
What the experiment revealed about
the current state of the OB practice...
BARRIERS TO ACCESS BETWEEN APPOINTMENT TIMES
CURIOSITY
wait until next
appointment
call in
CONCERN
Mom’s instinct to connect with
OB based on level of concern
CURRENT RHYTHM
OF CARE
•C
umbersome navigation, or not knowing who to call and when
•L
ack of continuity and feeling bounced around
iet
APPT
anx
ion
ipat
tic
y/an
• Weak short term memory of system; patients perceive they are not
being remembered
• Anonymity of care team members creates impersonal interactions
APPOINTMENT
•L
ack of privacy through verbal story repetition, especially to people that
moms do not perceive as being a member of their care team
BETWEEN APPOINTMENTS
APPOINTMENT
• Feeling like only the provider remembers/cares/knows/is accountable creates
a lack of trust in the OB department as a team and system
1-2 weeks until next appointment...
IMPACT
arriers to access elevate importance of appointments, discourage
B
self-awareness and makes ownership of care inconvenient
e.g. what will I do if I DO notice something different?
The only time mom feels she is noticed by OB is during her appointment
“Many women have questions or
concerns that come up at night but
figure out
on my own
wait until next
appointment
call in
don’t feel they are urgent enough
to call in or go to Triage...”
CURIOSITY
Mom’s instinct to connect with
OB based on level of concern
CONCERN
The appointment is the only time mom feels securely connected to
her care team
Because pregnancy issues are private, text-based communication is less
of a barrier than phone
The tool breaks through boundaries and allows for direct, personal
and trusted communication which supports mom’s empowerment to
address her concerns, care for herself and connect with OB as necessary
between visits
If mom feels like OB wants to hear from her, this shifts the locus
of the rhythm of care from OB and back to the mother
GAP WHERE PATIENTS
WANT CONTACT WITH
OB, BUT WAIT UNTIL THEIR
NEXT APPOINTMENT
The time between appointments
doesn’t feel as long because mom
feels connected. She doesn’t wait to
get her questions answered.
FUTURE STATE
figure out
on my own
asynchronous
communication app
call in
THEREFORE
3
CURIOSITY
Mom’s instinct to connect with
OB based on level of concern
CONCERN
Creating healthy outcomes
for MOMS & BABIES
ft i
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NT
RHYTHM
GTHENOnline
OB
RENNest
ST
Communities reinforces the role of OB as
supportive and guiding partner in moms’ prenatal experience.
“...a way to connect
JOY & CELEBRATION
SELF AWARENESS
CONFIDENCE
• The wide range of topics (medical and non-medical) and
serendipitous postings and responses from moms and providers
make the online environment feel fun and exciting.
SIGNAL
AUTONOMY
E
Moms were invited to join one of four online spaces. Three
of these spaces were extensions of groups that were already
meeting in person (e.g. centering and the DAHLC Pregnancy
Program). One group was a cohort of midwife patients who
had never met in person, but were given an online space to
share their pregnancy concerns, questions, and thoughts. These
three spaces were facilitated by OB nurses, a midwife, and
Creating healthy outcomes
CONTINUOUS & CO
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for MOMS & BABIES
IP WITH O NNECT
ILDI LATIONSH
two pregnancy advisors from the DAHLC Pregnancy
Program.
BU
B
ED
RE
All spaces welcomed medical
and
non-medical
conversations
Creating healthy outcomes
CONTINUOUS & CO
NG A
NNE
for MOMS & BABIES
ILDI LAchildbirth,
CTE children.
H OB raising
TIONSHIP WITand
pertaining to pregnancy,
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A S E
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CONFIDENCE & AUTONOMY
• Online communities give OB the ability to validate the care mom gives herself and
receives from others outside the clinic.
• Moms’ individual experiences and wisdom serve to benefit others in the
online community.
COMMUNITY
• Facilitating access to a community of peers honors the important impact social
connection has on a healthy and satisfying pregnancy.
“It felt more
connected
• When moms are given space to share their experiences, knowledge and concerns,
they become connected and invested in each other. They grow to care about the
wellness of other moms in the community, and feel cared for in return.
AUTONOMY
in
shift
B R AT I O
over the site”
N
SIGNAL
AL
NOR
MA
LC
W
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is watching
• In addition to their medical expertise, patients value the personal
experience of providers. This shift in dialogue strengthens moms’
relationship with the clinic and directs the culture of prenatal care
back towards a wellness model.
SIGNAL
than baby
center”
• Raising children is a catalyst for building relationships within a community, and many
first time moms haven’t built these networks yet – online communities help create
a support system for new families.
• The OB Nest online community creates an inclusive and non-intimidating
environment where moms of all type feel welcome.
“I didn’t think I
would find anyone
CONNECTION TO OB
on here with more
• Nest online communities give OB an opportunity
to push communication to mom, rather than her
always having to pull on the system to get
information: this ongoing dialogue strengthens
the relationship by making moms feel like
OB wants to hear from them.
experience than me”
– mom of three
“this is a place
to go when I forget”
NOR
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LC
Y
J
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W
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– mom of three
4
“I know Mary
STRENGTHE
CONFIDENCE
Provider Participation
• Even minimal involvement by providers gives moms the comforting
sense that they are present
• Providers act as hosts within the communities by being more active
when the communities are initially being formed (e.g. making the spaces
feel occupied and not vacant)
top user
CONTEXT • Rather than a dependent consumer of care, mom feels empowered as a contributor
ROLE
RHYTHM and valuable resource to others.
• The opportunity to share in the personal experiences of others gives mom a means
to provide and receive comfort, reassurance, and strength.
SIGNAL
NE
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STRENGTHEN
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STRENGTHEN
SELF AWARENESS
Local
• Connection to local community of moms creates greater trust
between users
• Access should be limited to local clients of Mayo’s OB department
and granted at the scheduling of NOBN appointment. Once granted,
access should be open-ended so moms can use postpartum
• Sharing a relationship to the clinic and providers made the culture
of the community feel more personal to moms
AL
CONTEXT
ROLE
RHYTHM
NOR
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RITE OF P
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STRENGTHEN
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Mayo-trusted
• Must be a private, Mayo-sponsored URL (e.g. not Facebook
or other public network)
• Invite non-medical experts to provide advice on wellness, exercise,
diet, etc. (i.e. DAHLC pregnancy program leader, Jamie Friend)
• Moms trust the Mayo brand and believe their privacy is being
protected on the site. To maintain this trust, the site must remain
free of advertisements.
AUTONOMY
– Mayo OB nurse and
• The OB Nest online community supports moms holistically with a forum
for important but non-medical topics (e.g. where to buy cloth diapers).
STRENGTHEN
Features
• Must have mobile capability
• Needs to include an easy way to search content
• Privacy settings must place discretion of personal information
in moms’ control
• Architecture of space should enable moms to create and join
special-interest subgroups
STRENGTHEN
FEATURES & TECHNICAL RECOMMENDATIONS
STRENGTHEN
Provider participation,Aconnection
to the Creating healthy outcomes
CONTINUOUS & C
DING TIONSHIP WITH ONNEC
L
for MOMS & BABIES
I
OB
TED the
BU
local patient community
and trust
in
RELA
Mayo brand distinguish and elevate this
SELF AWARENESS
space from other pregnancy forums.
CONFIDENCE
AUTONOMY
ideas from other moms”
NORMALCY & WELLNESS
SIGNAL
SELF AWARENESS
CONFIDENCE
and get information and
• Online communities create a space for moms to celebrate
pregnancy and support each other in motherhood.
W
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CONTEXT
INSIGHTS
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STRENGTHEN
DESCRIPTION
Creating healthy outcomes
STATS
EXT
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in
ft i
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ROLE YT
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CO
OB NEST ONLINE
CARE COMMUNITIES
STRENGTHEN
NT
A CONTINUOUS & CON
N
DING
for MOMS & BABIES
ECT
WITH O
IL
TIONSHIP50
BU
B
OB TEAM
PATIENT
ED USERS
RELA
SELF AWARENESS
Chris Domask
Jamie Friend
CONFIDENCE
AUTONOMY
Becky Copler
Tiffany Dudley
Mary Murry
Cindy Sutherland, RN
STRENGTHEN
RECOMMENDED
Experiment
CONTEXT
ROLE
RHYTHM
Experiment
RECOMMENDED
“I shared it with my
AT HOME MEASUREMENT
INSIGHTS
85-year-old grandmother
who was an OB nurse and had
never heard a baby’s heartbeat
Experiment
RECOMMENDED
DROP-IN FETAL
DOPPLER STATIONS
• At-home-measurements and fetal dopplers provide moms with
a sense of control, confidence, and reassurance on their own
time and in their own environments, giving them the tools to
determine a rhythm of care that works best for them
DESCRIPTION
CONTINUOUS & CO
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CONFIDENCE
AUTONOMY
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RENGTHEN
Creating healthy ST
outcomes
for MOMS & BABIES
LCY
STRENGTHEN
CO
shift in
CONFIDENCE
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SIGNAL
Fundal Height
• Moms need clarification and training on how to measure fundal height
Blood Pressure
• Moms need information on normal range of blood pressure measurements
LL
NE
SS
U
RIT
• In order to truly engage with the at-home monitoring experience, mom needs
to understand the significance of the measurements (transparency)
ACTIVATES PARTNERS & FAMILIES
• Many moms who used the doppler found that having the ability to share
the baby’s heartbeat gave them an opportunity to engage more loved ones in
the prenatal experience
SELF AWARENESS
SIGNAL
in
shift
N
B R AT I O
CELE
• At-home-measurements and fetal dopplers reduce patients’ reliability on the appointment
• The activity of taking weekly measurements activates partners and families to
participate meaningfully in mom’s pregnancy
NT
RITE OF P
ASS
EXT
STRENGTHEN
AUTONOMY
Weight
• Educate moms on the importance of a healthy overall weight gain and
encourage them to appreciate their unique growth process: numbers
should be interpreted as contributing to the big picture rather than a
measure of weekly success or failure
AL
AUTONOMY
ROLE
as the only source of reassurance
RHYTHM • Moms were unintimidated and felt confident using the dopplers on their own, as needed
RH
NA
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AGE
NGTHEN
CONTEXT
STRE
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SIG
NOR
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• By gathering their own measurements, moms have more information to share with
others and a richer social experience at their fingertips (e.g. story about how mom
was communicating her numbers with her family – not just her spouse – and they
were cheering her on)
JOY
SIGNAL
• Using the fetal doppler was an incentive for doing the other measurements: it
added an element of joy and excitement to a routine that would have otherwise
felt mundane
WELLNESS
• Access and use of fetal dopplers indirectly nudges mom to create occasions
for personal time where she can relieve stress and connect with the baby
W
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Doppler Drop-In Stations
• If dopplers are located in staffed locations, women expect that someone
is available nearby with the knowledge to help and answer questions
• Moms want a fast and reliable connection to OB should issues arise
• The location of a drop-in station sends strong contextual associations
that influence mom’s experience (e.g. Doppler stations in Express
Care suggests medical, home signals comfort and familiarity, DAHLC
communicates wellness and community)
• Because the heartbeat is easiest detected when lying down (abdominal
muscles can obscure sound if legs are bent), a fully-reclining chair should
be available in drop-in stations
• There is a need for well-designed educational materials in the
drop-in stations
5
JO
Doppler Training
• Provide mom with clear expectations that the heartbeat may be difficult
to detect and/or erratic
• Some moms made connections between daily activities and the effect on baby’s heart rate
• Through at-home-measurements, moms discovered that much of what happens
during the routine clinical appointments can be done on their own
STRENGTHEN
TECHNICAL RECOMMENDATIONS
• Hearing the baby’s heartbeat gives families reassurance- especially if they have
experienced previous miscarriages
• At-home-measurements are valuable self-check-ins that build mom’s knowledge
of her body
SIGNAL
Locations
Dan Abraham Healthy Living Center Lactation Room
CONTINUOUS & CO
St. Mary’s – Joseph Lactation Room
NG A
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Superior Drive Support Center
Lactation
Room
Mayo Clinic Northwest Express Care
CONFIDENCE
SELF-AWARENESS
in
shift
B R AT I O
N
Moms were given access to four “Drop-in Stations” around the Mayo campus
and Rochester. These stations were equipped with fetal dopplers, blood pressure
cuffs, and scales.
ROLE
“It helped my day
• Moms are mindful of what will cause them anxiety and choose to use the dopplers
only in a way that supports their confidence
STRENGTHEN
DROP-IN STATIONS
other people”
RHYTHM
RH
YT
H
Moms were given a blood pressure cuff, fetal doppler, and measuring tape. They
were asked to send these measurements, in addition to weight, to the OB Nest
team on a weekly basis.
able to share it with
• Privacy and a familiar atmosphere are strong drivers for
comfort: in-home usage enhances the experience of using
CONTEXT
the
fetal dopplers
ROLE
M
AT HOME MEASUREMENT
Creating healthy outcomes
for MOMS & BABIES
before. It was cool to be
• The routine of taking measurements as a family organically creates rituals for
positive health behaviors (e.g. story of dad taking his own blood pressure)
go better”
“Sometimes now when I go
to my appointments, if I don’t have
any major questions, it’s kind of like,
I feel like I could have done all of
Experiment
Experiment
AT HOME MEASUREMENT
DROP-IN FETAL
DOPPLER STATIONS
this on my own. That’s all they do
“I feel like
[during the appointments]”
I might have
— At-Home Measurement
gone to the doctor a
Participant
few more times. I think I
would have been more
worried if I didn’t
have it”
“Helped
me get through
the time between
appointments”
“...Nice to hear the heart
beat – it was awesome. One of my
friends was in her first trimester – you
know that phase when there’s no way of
knowing there’s really a baby there – you’re
not showing – it’s just that weird phase – so
she was jealous I had this.”
6
FEEDBACK FROM MOMS USING THE DROP-IN STATIONS
ONTINUOUS & C
GAC
EXT
AUTONOMY
• Video appointments give women the opportunity to connect to OB from
anywhere (as long as they have adequate technology and privacy)
SELF AWARENESS
CONFIDENCE
AUTONOMY
in
shift
B R AT I O
N
ROLE
shift in
CO
NT
STATS
STRENGTHEN
LS
NA
RH
YT
H
SIG
shif shi
t in ft in
STRENGTHEN
STRENGTHEN
LEARNINGS
CELE
DESCRIPTION
CONTEXT
ROLE
RHYTHM
Creating healthy outcomes
for MOMS & BABIES
M
ONN
N
ECT
ILDI LATIONSHIP WITH O
6 PATIENT USERS
BU
B
ED
RE
RITE OF P
ASS
A
VIDEO ROB & NOBN
APPOINTMENTS
OB TEAM
Chris Domask
Dr. Harms
Dr. Creedon
GE
Experiments
RECOMMENDED
• May not be convenient for working moms – many do not have a private space to speak
freely over video conference
U
RIT
AL
Low-risk patients were given the option of doing their
next appointment using videoconference technology.
Patients used either Skype or Facetime to talk to their
providers either from their homes or their offices.
Patients who elected to have their appointments in this
format were either asked to participate by their nurse
over the phone or by their provider at their previous visit.
Patients were screened for the following criteria:
low-risk pregnancy, no psycho-social issues,
no past or current history of sexual, physical,
or drug abuse, no prior complications during
pregnancy, over 18 years old.
SIGNAL
LL
S
NE
S
• Technical constraints within videoconferencing software make it more complicated to
involve partners in the visits
W
LCY
7
MA
Video NOBN
• Because there is no physical exam during a woman’s first nurse visit, this is a good
opportunity for a video visit
• For this experience to be proactively planned, moms would need to be screened at the end
of their previous pregnancy and noted if they are a candidate for this experience (low risk
pregnancy, no history of abuse or psycho-social issues). Then PAC’s could offer the option
when patients first call to schedule their NOBN visit
• Video appointments, by showing just the participants’ faces eliminates other
environmental distractions
NOR
E
Y
• To make women feel comfortable, provider should disclose anyone in the room that may
not show on the screen
• For this to truly be a convenient option for moms, they would also need to have their own
measurement equipment to report their fetal heart tones, fundal height, weight, and blood
pressure during their appointment.
• Would need careful screening and confirmation at least 1 day prior to identify if patient has
actual pressing concerns – otherwise this will lead to more visits
• Tech privacy concerns – patients do not know who else is with the provider!
• Setting and lighting need to be considered when creating this experience
• Selection process for who is a good candidate is very cumbersome and time consuming.
There was a lot of digging in the record by clinical staff
JO
TECHNICAL RECOMMENDATIONS
• Physician and nurse perspective: this interaction was better than the phone because
they can “read a patient’s eyes” and know if there is something they aren’t telling them
• Patients were able to work up to the point of their appointment and then immediately
return to working
• Saves facility space and CA rooming time
• As a stand-alone solution, this interaction is simply a virtual replacement for the same
rhythm of care
SIMULATION OF THE DURATION OF TIME
AN APPOINTMENT ACTUALLY CONSUMES
Check
in
Leave
work/home
Drive to
appointment
Park
Walk into
building
Rooming
with CA
Wait for
Appointment
Schedule next
appointment
Appointment
Walk
to car
CURRENT STATE
TIME THAT A VIDEO APPOINTMENT TAKES
Return to
home/work
Drive to
work/home
RH
Y
NA
SIG
s
shi
ft i hift i
n
n
STRENGTHEN
ROLE
shift in
N
SELF AWARENESS
CONFIDENCE
AUTONOMY
CELE
in
shift
B R AT I O
STRENGTHEN
CO
NT
RITE OF P
ASS
A
EXT
GE
N
STRENGTHE
AL
NA
SIG
EXT
NA
LS
RH
YT
H
EXT
SIG
shif shif
t in t in
AGE
ROLE
SELF AWARENESS
NT
STRENGTHEN
CO
CELE
L
E
LN
Y
E
RH
SS
YT L N
LH
M
S
ES
RIT
UA
L
RIT
W
s
shi
ft i hift i
n
n
E
LS
AUTONOMY
Creating healthy outcomes
for MOMS & BABIES
OY
the myriad dimensions of health that exist beyond the medical understanding
of pregnancy
MA
LCY
JO
N
ORM
A
J
LCY
• Because many women will have several pregnancies, post-miscarriage and
post-partum calls demonstrate commitment to a long-term relationship.
• Pregnancy and child-birth are pivotal life events and proactive calls signal that
OB acknowledges the scope of their responsibility and honors their involvement
in this process
in
shift
B R AT I O
N
ROLE
shift in
STRENGTHEN
CO
NT
NOR
EXT
WELLNESS & JOY
CONTEXT
SIGNAL
• Proactive calls prevent mom from feeling dismissed post-delivery
ROLE
SIGNAL
RHYTHM
• Post-miscarriage calls demonstrate a commitment to moms’ wellbeing beyond
clinical outcomes by acknowledging the significance of EVERY pregnancy
experience (even when it doesn’t result in the delivery of a healthy baby)
N
STRENGTHE
• Connecting with women post-miscarriage communicates that OB respects
STRENGTHEN
CELE
• Proactive calls may give OB a way to more accurately diagnose postpartum
depression, the #1 complication after delivery
AL
SIGNAL
• Post delivery calls are opportunities for OB to acknowledge moms’
accomplishment and celebrate the birth of her child
L
E
LN
SS
U
RIT
Proactive post-partum calls
• Many postpartum issues are very personal and intimate: mom is most
responsive when the call is from someone familiar
• A loose question guide will ensure all postpartum topics are covered
• Calls should take place approximately one week after delivery because this
is when women often have the most questions and concern
CONFIDENCE & AUTONOMY
• For some moms, post-partum calls can fulfill the need for a follow-up
appointment. If her questions and concerns are addressed during the call,
mom may feel confident enough to opt out of her postpartum visit
in
shift
B R AT I O
N
ROLE
shift in
in
shift
RITE OF P
ASS
N
B R AT I O
CELE
L
UA
ROLE
RHYTHM
CONFIDENCE
W
NA
calls communicate that OB is a reliable partner outside
CONTEXT
of scheduled
appointments
STRENGTHEN
SIG
RENGTHEN
STProactive
SELF AWARENESS
All calls
• To be valuable to mom, proactive calls need to be regarded as an important
and necessary part of a woman’s pregnancy care; these are not simply
customer service calls
SELF AWARENESS
• To deliver high quality care, postpartum callers should be knowledgeable
CONFIDENCE
in lactation and infant care advice
AUTONOMY
• The OB care team staff making these calls had a difficult time connecting
with moms over the phone, making this interaction inefficient without better
tools to connect. The asynchronous communication tool could reduce some
of the “phone tag” involved in this interaction.
GE
SIGNAL
CONTEXT
ROLE
RHYTHM
AUTONOMY
CONTINUOUS & CO
NG A
NNE
ILDI LATIONSHIP WITH O
CTE
BU
B
RE
D
TECHNICAL RECOMMENDATIONS
INSIGHTS
STRENGTHEN
CONFIDENCE
Nurses and Midwives made calls to patients after three different
pregnancy events: miscarriage, post-partum, and visits to triage.
The purpose of these calls was to check in with these women to
see if how they were and if they needed anything from OB.
RITE OF P
ASS
A
Creating healthy outcomes
for MOMS & BABIES
M
NT
CO
shift in
DESCRIPTION
STRENGTHEN
LS
RH
YT
HM
N
LL
E
SS
U
RIT
E
s
shi
ft i hift i
n
n
LCY
W
JO
Y
GE
STATS
CONTINUOUS & CO
NG A
NNE
ILDI LATIONSHIP WITH O
CTE
BU
B
RE
D
STRENGTHEN
RITE OF P
ASS
A
MA
PROACTIVE CALLS
OB TEAM
21 CALLS TOTAL
Creating healthy outcomes
A CONTINUOUS & CON
G
AnneILBaron
N
NEC
DI
for MOMS & BABIES
TIONSHIP WITH OB
A
T
L
BU
E
E
R
D
Rhonda Fishbaugher
Katie Slifko
Deanna Griebenow
NOR
RECOMMENDED
Experiment
W
N
ORM
A
LCY
J
E
OY
Proactive calls post miscarriage
• A requisite for excellent care
Proactive calls post-triage
• Patients had no relationship with the care team members who called
them for this experiment. These calls were very short, and seemed like an
annoyance to the patients.
• Hypothesis If care team members have an established relationship with
the patients they are calling post-triage, this could be an opportunity
to strengthen their connection, and make the moms feel validated in
connecting with OB about their concerns, and confident in the OB
department as a system and team.
8
CONNECTED & CONTINUOUS
• Proactively reaching out to mom after significant events strengthens
her relationship with OB by making her feel visible even when away
from the clinic
• Calls communicate that mom is remembered and acknowledged by
the system
• Skilled staff discuss wide range of meaningful topics including:
• Labor follow-up (story telling/sharing)
• Healing and comfort level
• Postpartum depression
• Lactation issues
• Purpose of 6 week follow-up appointment
OB
LS
NA
SIG
s
shi
ft i hift i
n
n
N
STRENGTHE
EXT
AGE
ROLE
shift in
STRENGTHEN
CO
NT
RITE OF P
ASS
N
in
shift
B R AT I O
CELE
VIDEO IN A FRIEND
OB TEAM
Pat Hinck
Dr. Harms
Alan Neis
CONFIDENCE
AUTONOMY
INSIGHTS
SIGNAL
STATS
LL
S
NE
W
CONTINUOUS & CO
NG A
NNE
ILDI LATIONSHIP WITH O
CTE
BU
B
RE
D
ROLE
Creating healthy outcomes
for MOMS & BABIES
JO
Y
LS
NA
RH
YT
H
M
Y
CONTEXT
ROLE
RHYTHM
STRENGTHEN
EXT
SIG
GE
ROLE
SELF AWARENESS
CONFIDENCE
• Because there is such a strong “compartmentalization” between
the clinic and the rest of life, patients don’t realize this is possible,
even though many possess the technology to make it happen
AUTONOMY
ACTIVATES FAMILIES
CELE
L
UA
N
LL
ES
S
RIT
SIGNAL
W
NOR
MA
LCY
E
Y
9
JO
• OB needs a strong and reliable internet connection, for this experience to
not be disruptive to the clinical experience
• Essential for provider to be accommodating to the virtually connected
person and treat them as though they’re physically present
• OB should welcome and encourage this experience but leave woman
in control of holding the device
• Create public awareness of this opportunity (e.g. signage in waiting rooms)
• Lessens perceived boundaries between life and clinic
AUTONOMY
in
shift
STRENGTHEN
CO
shift in
N
B R AT I O
STRENGTHEN
TECHNICAL & DESIGN RECOMMENDATIONS
NORMALCY
• By simply giving moms permission to engage in this experience,
it signals to mothers that they are in control of who they include
in their care experience and how they include them.
NT
RITE OF P
ASS
A
N
STRENGTHE
shif shif
t in t in
N
Moms often want to include their
STRENGTHE
partners or loved ones in their OB
visits, but this isn’t always possible. This
experiment gave moms the opportunity
to include these people using video
conference technology. Of the women
who participated, several were from
the Rochester area whose partners
were unable to get away from work long
SIGNAL
enough to come to the appointment.
Others who participated had spouses or
partners that were living in other parts
of the country or world that were unable
to be present for much of these women’s
pregnancies. Most participants used their
own technology and devices to connect,
and needed very little help from clinical
staff or the OB Nest team.
“I needed her
to be there”
• For many women, this is a commonplace way to communicate
with their partners and support people
ROLE
NOR
MA
LC
E
DESCRIPTION
SELF AWARENESS
12 PATIENTS
& PARTNERS
S
R
A
ITU
L
Experiment
RHYTHM
STRENGTHEN
RECOMMENDED
TED
RH
YT
HM
R
SIGNAL
• Limiting the number of people allowed in the ultrasound room
prioritizes the medical purpose of the appointment over the
mother’s experience. Welcoming the use of video call technology
signals that OB supports the involvement of families without
compromising the high quality clinical care being provided
(pending the connection runs smoothly).
• Without this opportunity, loved-ones simply would have missed
valuable opportunities to share in moms’ pregnancy experiences
LEADERSHIP OPPORTUNITY
• With a tech-savvy patient population, OB is well-situated to lead the
way in virtually connecting families into patients’ clinical experiences
First-time mom whose
husband is in Canada, unable
to re-enter the U.S. due to visa
issues. Both are expecting that
this baby will be their first and
only baby together.
Story 1:
Woman’s partner is
in San Francisco and is
moving to be with her in
the fall. She is committed to
bringing her partner into her
prenatal experiences and wants
her to be bonding with the
baby as much as she can before
he or she is born
“I wanted him
there to hear the
heartbeat for the
first time”
“I needed to know
he was there if something
went wrong. I wanted him to
hear when I hear because it
would be painful to
repeat myself.”
Story 2: Woman’s family lives
just outside of Rochester and her
husband couldn’t get enough time
off work to come to appointment.
She knew the visit was “routine”
but still wanted to have him
there in case there would
be any bad news. She didn’t want
to repeat it if there was.
“It give us the opportunity to go through this awesome event that you can
never get back, together. we’re both so excited to be able to have this baby.
I know if he was here, he would be here, at the appointment. This is just
another opportunity to get closer and be able share these times with our
little one... you never get those back. And obviously we’re not going to have
any more of them, this is it. it just helps bring us closer helps him feel like
he can be involved. the downfall is that, i can see it very easily, if you don’t
have these kinds of options, people become disconnected. and i don’t want
that – and neither does he. [...] he was able to see the baby moving in there
and the heartbeat which was really cool, he wanted to see that, it was really
disheartening for him to not be able to see that for the first time... [...] We
were doing it together.”
Experiment
CONFIRMATION
CALLS
Moms who called OB to schedule their NOBN appointment were given the option to speak
with another mom about her past experience with the various care options OB offers.
Experiment
OB TEAM
4 CALLS
Anne Pahl (mom)
Kara Elpert
Beacy Peterson
Lisa Spearman
Karren Karlen
YOUR CARE
OPTIONS CALLS
STATS
Mom’s Mental Model for Care Options (excluding centering)
RESIDENT
OB
MIDWIFE
The same person
throughout pregnancy
and delivery
Traditional model
of care (at Mayo)
Alternative model
of care
Default Care
(no decision)
Less likelihood of
medical intervention
Safer, less risk
More perceived continuity
• Moms currently perceive midwife care as an “alternative” path, while OB care is seen
as the default.
Greater likelihood of
medical intervention
Unable to handle any
complications
• Many moms have a misconception that seeing an obstetrician (for their healthy
pregnancy) is safer than seeing a midwife.
Less continuity of
provider
Greater autonomy
• Many moms choose to see an OB in case something goes wrong – they may not be
feeling confident that they can get the right level of specialty care when they need it.
Doctor is driving
LEARNINGS
• Currently the “official” education on options is delivered during NOBN visit, yet most
moms have scheduled their NOBR prior to this.
• The decision point when patients call OB to schedule their first appointment is during the
call with the PAC. Because moms are simply calling to get an appointment scheduled,
this is not an appropriate moment for decision making.
• Decision-making content needs to be available at a touch point prior to making the first
appointment. (make readily accessible on OB’s website).
• Be transparent about low-risk pregnancy outcomes in order to allow a patients choice to be
about the philosophy of care rather than safety.
• Provide moms with a statement that encompasses what OB as a division believes to be
a successful prenatal experience for moms – regardless of care choice. (e.g. Guiding and
Partnering with women during their physiological pregnancies to create healthy, satisfying
experiences resulting in healthy babies and mothers).
• Be transparent about the rhythm of care patients are choosing for their pregnancies. Show
them now the care options are (or aren’t) different.
STATS
Nurses called low-risk pregnant women 2-3 days before their next appointment to see
if they would be willing to extend their appointment time by two weeks OR substitute
their upcoming appointment with a nurse visit or video ROB appointment. 12 calls
total calls were made. When given the option, four out of four patients chose a nurse
visit in place of their ultrasound visit.
LEARNINGS
• Moms are accustomed to making care plan decisions with their midwife or doctor in their office
visit – not with a stranger over the phone
• 2 – 3 days prior to an appointment, many moms have already made their plans (e.g. time off
work, or daycare) to come in for their appointments. To change these plans at this point is more
a disruption than a convenience.
• Signals to mom that her rhythm of care is arbitrary and not thoughtfully planned
• Moms have made a verbal contract with their provider during their appointments on when their
next appointment needs to be. Confirmation calls from an unrecognized member of her care
team sends a confusing and contradictory message to mom
• Moms are coming in when they are told to come in. If the provider says she needs to come
to the clinic, then she needs to come in to the clinic
• Confirmation calls reinforces the belief that the nurse is the barrier to mom seeing her provider
• If appointments are to be replaced or substituted, it needs to be done at the commencement
of care, and not at the moment of care
For a woman to feel confident changing her rhythm of care:
• A recognized and trusted member of her care team needs to proactively plan her care with her
• She needs to know who else – behind the scenes – is looking after her and her baby (e.g. MFM
physicians reviewing ultrasounds)
• The experience cannot make mom feel like she is giving up her appointment because OB is too
busy to see her
For low risk pregnancies, is there going to be a choice between OB and midwife care?
If there are choices:
12 CALLS
• She needs the ability to hear the baby’s heartbeat
Trained to handle
complications if anything
goes wrong
RECOMMENDATIONS
OB TEAM
Rhonda Fischbaugher
Ann Baron, Dr. Boldt, Dr. Long
Mary Murry, Dr. Harms
The current decision architecture for
mom’s care option choice:
1. What provider do you want to see?
2. When are you available?
From this first touchpoint,
this decision architecture
suggests patients will have a
provider-centric relationship
rather than a departmental or
team-based relationship for
their pregnancy care.
• She needs a simple way to get her questions answered.
If mom knows an MFM physician is reviewing her ultrasound, then the 18-week ROB visit is an
opportune time to have a nurse visit instead of a provider visit.
• This is a visit where the nurses are already delivering patient education.
• Mom is getting “bounced around” less (i.e. during a standard care ROB visit, she is seeing
a CA, a CNM or OB, and a nurse) because she is only seeing a nurse.
• If the “Connected Care” Model enables mom to connect with her nurse from weeks 18 to 36,
this is an opportune moment for her to reestablish and build confidence in this connection.
• This is a moment to capitalize on the 2 hour time investment that is happening during the NOBN visit
by building a relationship that will ideally give mom confidence and reassurance during her pregnancy
outside of the clinic walls.
10
Experiment
TRACKING JUST
COME IN ADVICE
SURVEY WAS CONDUCTED IN FIVE DAYS OF JANUARY 2012
SURVEYS RECEIVED: 104
Percent of calls resolved by phone triage only ~52.9%
Percent of calls resolved after consultation with midwife or physician ~26.9%
Percent of visits by patients that could have been avoided if the group were to have decision was ~3.8%
For this experiment, we asked nurses to tally the type of call
and the outcome to better understand where the greatest
opportunities are for reducing the need for appointments.
Per protocol
WE HOPE TO LEARN
•H
ow often does a call to the nurse line result in the patient
being told to come in to the clinic?
•C
ould the need for these trips in to the clinic be prevented
if we had other systems and processes in place?
6
3
Avoidable scheduled visit
3
Per physician advice
Avoidable to Triage
Per physician advice
Per protocol
1
1
7
12
Total Patients: 104
9
Patient concern resolved via phone
Created a tracking tally sheet for nurses on the nurse line to track the
number of calls that result in each of the following:
55
• Resolved via the phone by the nurse or per the protocol
28
• Told to come in, but trip might have been preventable if a provider had
been available to talk with her
• Told to come in because of protocol, but I (the nurse) don’t believe she
really needed to
-
• Told to come in and I (nurse) think that was necessary
• Found a doctor / midwife to sign off on her not coming in
• Tracked the names of the patients who are told to come in on a separate
sheet for future analysis
11
-
Physician/midwife available to advise,
therefore patient concern was resolved
Patient was advised to come to Triage
Patient was advised to schedule
a clinic visit
Experiment
TUMMY PHOTOS
2 PATIENT
PARTICIPANTS
(RECRUITED >40)
STATS
TECHNICAL RECOMMENDATIONS
• The experience must be mobile, so moms are not required to have their
photos taken from the same location throughout their entire pregnancy
• For this activity to create a keepsake of the experience, it needs to enable
animation or a building progression of the photos (e.g. baby belly app)
• This activity requires assistance of a support person
LEARNINGS
FPO
DESCRIPTION
Moms were asked to take weekly photos of their
pregnancy progression. They were given a backdrop
with a grid and instructions to take the photo from
the same position each week while mom’s tummy
is exposed.
12
• In their current state, moms found the backdrops to be intrusive and
cumbersome to use, providing no value to the experience.
• Many moms – especially moms who are overweight or body-conscious –
have no desire to take photos of their bellies as they progress through
their pregnancy
• Because of the precision needed to line up the photos, moms found the
activity overwhelming and very clinical
• Because the act taking tummy photos throughout pregnancy is an
opportunity for her to express creativity and individuality, the moms
who participated in this experiment made the effort of taking their own
personal sets of photos
• If moms are confident that their care team gets value from receiving
these photos, they have a more positive reaction to this activity
• A consensus needs to be made on the level of precision needed to make
these photos clinically relevant, while still aligning with what we can
realistically expect moms to do on a regular basis
Experiment
PATIENT-CENTERED TEAM CARE
This experiment highlighted the need
for care management tools.
Patients were provided
access to an online
website, which allowed
them to communicate
with their provider, while
archiving all of their
information in one place.
It also allowed patients
the opportunity to invite
other people relevant
to their pregnancy care,
such as family members,
Primary Care Providers,
social workers, other
subspecialists, etc, to
participate in collaborative
discussions about
their care.
PROVIDERS
Rhonda Fishbaugher
Dr. Brost
Dr. Rose
Dr. Baldwin
Dr. O’Brien
Dr. Lombardo
Dr Davies
Dr. White
12 PATIENTS
10 ACTIVE ACCOUNTS
1 HUSBAND-CREATED
ACCOUNT
STATS
Experiment
TECHNOLOGY
SURVEY
They Have the Technology: Results from 294 OB Patient Connectivity Surveys
Roger Harms MD, Dan O’Neil MSIE\MBA, Marnie Meylor MFA, Matthew Gardner MFA\MBA, Mekayla Beaver MS , Jason Egginton MPH
Mayo Clinic Center for Innovation, Rochester, MN
Objective
Our project explored ways of connecting with expectant mothers.
During this phase of the exploration, we were looking to evaluate
expectant parents’ access to- and comfort with- communication
technologies and Obstetric (OB) virtual interactions using a
survey. We also sought to determine the percentage of patients
who would volunteer to help redesign the OB experience.
Study Design
CFI and OB\GYN partnered to think about new ways of connecting
with expectant parents. The study comprised of a short survey
that was designed to complement a larger body of work that
includes qualitative interviews, observations, and small prototype
experiences. The survey was focused on uncovering additional
barriers and/or advantages to potential tools that have been
identified through other work.
A 25-item questionnaire was developed by Center for Innovation
(CFI) designers based on consensus among OB clinicians. The
1-page paper survey was distributed for 5 days in December,
2011. The survey was designed to evaluate which technologies
might be useful for patient’s interaction with OB. We determined
the percentage of patients who would volunteer to redesign
the experience. We explored patient willingness to use texting,
e-mail, instant messaging, video calls, Facebook, smart phone
applications, online portal or online groups.
Methods
CFI and OB\GYN partnered to think about new ways of connecting
with expectant parents. This survey will help us know which
efforts we should pursue in more detail.
About the Respondents (N=294)
Surveys were completed by 294 expectant mothers waiting for
visits. The mean age of responders was 29.7 ±4.9 years with due
dates from October 2011 (post-partum) through August 2012.
In addition to demographics, our survey asked:
to Patients
Technology– Most Patients
Have Access (96%)
It would be nice to add question in email to your provider
Texting is a good alternative
160 Characters is not enough
Use for appointment reminders
Technology– Most Patients
Have Access (96%)
2%
38%
Have internet, but
no smart phone
Don’t have access
to internet, but have cellphones
1%
1%
Have no access to technology,
(cellphones or internet)
Unknown
58%
Have smartphones
with internet
Facebook
Discussion and Analysis
In a cohort of young, technologically-familiar OB consumers, use
of non-didactic (“distance”) methods of patient interaction were
appealing, especially for “established” electronic methods such
as e-mail. Access to these modes of communication is prevalent.
Depending on patient preferences, the rhythm of face-to-face
encounters could be adjusted by using more distance technologies
for interacting between visits. Such measures may better fit
patients’ expectations and circumstances, and spare didactic
clinical capacity for higher-risk, higher-complexity patients.
Patient Use of Technology Tools
I’m on Facebook all the time and it is very easy to use
Not private enough
Too public
OB Nest Technology Survey
USE Currently
WOULD Use for OB
Email
3.3
Email
Text
3.0
Text
Facebook
2.7
Data Collection – Technology Access
Study Setting
Patient Survey Volume
• Surveys received: 294
• Volunteers interested: 80
• Statistics are consolidated in a database for future use
Facebook
2.5
1.9
1.5
SmartPhone Apps
Not collected
SmartPhone Apps
1.8
IM
1.6
IM
1.3
Video Calls
1.6
Portal
1.6
Online Groups
1.3
Scale on 1 (none) to 4 (constant)
average responses
Surveys were completed by 294 expectant mothers waiting for
visits. The mean age of responders was 29.7 ±4.9 years with due
dates from October 2011 (post-partum) through August 2012.
• Survey was conducted in five days of December 2011.
• Surveys were available at check-in at OB Office in Methodist
Hospital, Rochester, MN.
• Based on clinical situation, not all patients were approached for
a survey so we can not calculate a response rate.
Email
Would be great for appointment reminders
Texts are simple, easy, convenient and fast-response
• How often do you use the following technologies? Text, Email,
IM, Video, Facebook, Portal, Online Groups
• Would the person be willing to be contacted to be part of trying
Technology Available
some tools in the future?
Email is the best way to reach people & easy to use
Text
• What technology do you have access to use? Computer, Internet,
Cellphone, SmartPhone
• Would you want to interact with the OB department via any of
these methods? Text, Email, IM, Video, Facebook, SmartPhone
Apps, Portal, Online Groups
Quotes from Patients
Video Calls
Portal
Online Groups
1.4
1.9
1.4
Scale of 1 (no way) to 3
(certainly) average responses
Results
Most respondents had access to a computer, internet, and cell phone (95%,
97%, 99%, respectively), while 60% owned “smart” phones with internet
and applications. Most felt likely or certain they would connect with providers
by email (92%), text (68%), Facebook (42%) and smartphone (56%). About
1 in 4 might participate in future OB quality improvement efforts (27%).
Policy Implications
There are over 4 million children born-in the United States every year and
only 40,000 OB\GYN providers. As a result, care management is stretched
and there is increased pressure for productivity and cost improvement.
However, OB Care represents a fixed-fee model based on fee for service. We
have an opportunity to provide better care and improved patient relationships
at lower cost – if we can reach patients via electronic means. Based on the
results of the study, it would appear that we can reach the majority of low-risk
patients via at least some of our tools for virtual prenatal care.
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